Danielle Ofri: Translating the Foreign Culture of Medicine

Today's post is from Danielle Ofri, writer and practicing internist at New York City's Bellevue Hospital. She is the editor-in-chief of the Bellevue Literary Review. Her newest book is Medicine in Translation: Journeys with my Patients. This post originally appeared at her Medicine in Translation blog at Psychology Today.

If asked what a doctor does, most people would probably come up with the standard description of diagnosing and treating disease, usually while wearing an ill-fitting white coat. Before I entered practice, even during my medical training that probably would have been my answer too.

But my years in the trenches of real medicine have altered that definition greatly. I do spend time doing the things I learned in medical school like diagnosing disease and writing prescriptions, but that turns out to be only a part of the job, often a very small part.

Much of the time I find myself acting as sounding board. Recently I saw one my regular patients, a woman whose main medical issue is hypertension. But for most of our visit she spoke, often tearfully, of the strain of raising grandchildren since her daughter died of HIV. We never really got to her hypertension, and I certainly didn't have any easy answers for her difficult life situation, but this seemed to be the only time and place that she could devote to her own issues.

A good portion of my time is spent being a teacher. So much of medicine involves education-- talking about what a disease means, which medication side effects are important to watch for, how to plan a healthy diet, which screening tests are important, what a particular diagnostic test entails, what the various lab results mean, and so on.

Then there are the many niggling clerical tasks-- filling out forms, calling insurance companies, obtaining prior authorizations--the annoyances that add an unpleasant grumble to the day.

But when I think about what might be the overriding job description, the one that not only incorporates the above but also extends to the more existential aspects of medicine, I see the doctor as a translator.

For most people, medicine is a foreign country, with its own language, customs, and mores. My patients are immigrants to this country, and many feel very disoriented. My job, as their physician, is to translate this alien world for them, to help them acclimatize and hopefully thrive.

Jhumpa Lahiri used a beautiful phrase for the titular story of her marvelous first book: "The Interpreter of Maladies." Doctors, of course, fit this bill-- we are constantly interpreting our patients' maladies-- but we are also interpreting the greater culture of medicine.

Being a translator can often be burdensome. It is not enough, as a doctor, to assemble the clinical details, deduce a diagnosis, compose a treatment plan. You also have to be sure the patient understands it all-and that can be an infinitely harder and longer process.

But there are also many joys to being a translator. I once had a new patient who suffered from both osteoporosis and osteoarthritis. Her previous doctor had worked out a meticulous treatment plan, including hand-written charts of how and when to take each pill. Yet, the patient was entirely confused about her medications.

After a complicated conversation with many false starts, I finally realized that the patient thought that osteoporosis and osteoarthritis were one and the same thing. The pills for each condition were dumped into a communal pill bottle and taken in a random manner.

My "diagnosis" was that this patient did not have a full understanding of the language of medicine and that these terms had never been fully translated for her. We spent a long time going over the difference between osteoporosis and osteoarthritis. It wasn't easy, but by the end of our visit she had a basic comprehension that these were two different diseases and the medicines were treating entirely different things.

This patient had many more serious medical conditions to contend with, but she seemed delighted at this small victory, that she finally understood these diseases, that she finally "owned" this aspect of her health.

There was, of course, no place on the insurance form for this sort of effort. The insurance company would never pay my hospital for the painstaking "translation" work that is so critical to good health. But that's the reality. Luckily there is the patient's happiness and hopefully improved health that is the real payback.

Comments

[Steve]

"Any worth-his-salt physician knows that no on is 'cured'.... We want home runs, antibiotics to 'cure' man with a single shot in the buttocks. But after you've knocked the ball into the center-field bleachers you still have to go home to supper. So what? The ball park lies empty-eyed until the next game.... The cured man, I want to say, is no different from any other. It is a trivial business unless you add the zest, whatever that is, to the picture." (William Carlos Williams, Autobiography; ch. 43, "Of Medicine and Poetry")

[Bill Baar]

The CPT codes for Patient Education are:

99071 Educational supplies, such as books, tapes, and pamphlets, provided by the physician for the patient's education at cost to physician

99078 Physician educational services rendered to patients in a group setting (eg, prenatal, obesity, or diabetic instructions)

98960 Education and training for patient self-management by a qualified, nonphysician health care professional using a standardized curriculum, face-to-face with the patient (could include caregiver/family) each 30 minutes; individual patient

98961 Education and training for patient self-management by a qualified, nonphysician health care professional using a standardized curriculum, face-to-face with the patient (could include caregiver/family) each 30 minutes; 2-4 patients

98962 Education and training for patient self-management by a qualified, nonphysician health care professional using a standardized curriculum, face-to-face with the patient (could include caregiver/family) each 30 minutes; 5-8 patients

So who is the carrier who doesn't reimburse you???